Wednesday, February 8, 2017

Making Sense of Our Compulsions

Checking our smartphones every few minutes. Making sure every spice jar is in the exact right place in the rack. Shopping. Stealing. Working nonstop. Hoarding. “Compulsions come from a need so desperate, burning, and tortured it makes us feel like a vessel filling with steam, saturating us with a hot urgency that demands relief,” Sharon Begley writes in her new book, Can’t Just Stop. “Suffused and overwhelmed by anxiety, we grab hold of any behavior that offers relief by providing even an illusion of control.”In a time of extreme anxiety for many of us, Begley’s book feels particularly relevant. In chapters that run the gamut from obsessive-compulsive disorder to compulsive do-gooding, Begley—a senior science writer for STAT, whose previous books include The Emotional Life of Your Brain and Train Your Mind, Change Your Brain—explores how behaviors that range widely in both character and extremity can come from a common root. “Venturing inside the heads and the worlds of people who behave compulsively not only shatters the smug superiority many of us feel when confronted with others’ extreme behavior,” she writes. “It also reveals elements of our shared humanity.” Begley and I spoke by phone about what anxiety is, exactly; her own compulsions; and whether it’s possible to have no compulsions (not likely).

What is the definition of “compulsion,” as compared to addiction and impulsive behaviors?

This was the first thing that I had to grapple with. The first thing I did was go around to psychologists and psychiatrists and start asking, “What is the difference between these three things?” To make a long story as short as possible, they really didn’t have a clue, or at least they were not very good at explaining it—to the extent that the same disorder would be described in the DSM, the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association, using “compulsive” one time and “impulsive” the next.

So where I finally came down, after finding people who had really thought about this, is as follows. Impulsive behaviors are ones that go from some unconscious part of your brain right to a motor action. There is very little emotion except for that feeling of impulsivity. There’s certainly little to no thought involved.

Behavioral addictions—and this is where I thought it started to get interesting—are born in something pleasurable. If you’re addicted to gambling, it probably is because, at least when you started, it was a whole lot of fun. You loved it. You got a hedonic hit, a pulse of enjoyment. And certainly as things go along, a behavioral addiction like gambling can cause you all sorts of distress and destroy your life. But at least at the beginning, it brings you extreme pleasure.

Compulsions are very different. They come from this desperate, desperate need to alleviate anxiety. They’re an outlet valve. The anxiety makes you want to jump out of your skin, or it makes you feel like your skin is crawling with fire ants. And what compulsions do is bring relief only after you have executed the compulsion, whether it is to exercise, or to check your texts, or to shop, or to keep something if you’re a hoarder. And crucially, compulsions, although they bring relief, bring almost no enjoyment except in the sense that if you stop banging your head against a wall, then it feels good to stop.

Why, when you started to decipher this taxonomy, did you decide to focus on compulsions in particular?

The behaviors that I found most interesting turned out to be compulsions. I mean, sometimes the same behavior can fall into different categories. But for most of the things that I was looking at, especially behavior having to do with electronic media, those turned out to be compulsions.

I also thought it fit in with the way we all live these days. That anxiety just seems to be built into so many of the lives we lead. And therefore, I was interested in how this anxiety manifests itself, and how people deal with it. The prevalence of anxiety diagnoses is much higher these days than depression, even among college students, who have long been suffering in great numbers from depression. Just a couple of years ago, anxiety surpassed depression as the most commonly diagnosed mental health diagnosis in college students. Something about the way we live is ratcheting up anxiety in a whole lot of us. And that seems to be why compulsive behaviors are becoming more common, something that we all go to in order to survive.

Everyone knows when they’re feeling anxiety, but what is it, exactly?

It’s a feeling that you are under threat, that you are at risk. Sometimes you know exactly what it is. If you’re walking on a dark, deserted street, then the anxiety you feel is probably because you understand that something bad can happen to you. But in many cases the source of the anxiety is not at all clear.

So I’ll give you just one example. Now that online shopping is ubiquitous, if you’re in a brick-and-mortar store, the number of choices is finite and not that large. But if you’re shopping for shoes on Zappos, you may be on page 19, and there’s a little voice in your head saying, “Well, wait a minute, don’t press buy, what if page 20 or 21 or 73 or 119 has an amazing pair?” You never really feel that you have settled in a safe place, that you have made the right choice, that you can stop. So again, that’s not as severe a threat as you’re walking down a street and could be mugged, but it still triggers a sense of anxiety: “What if I’m not making the right choice?”

In large part, the book has to do with taxonomies and classifications. It seems to me that there is, in your view, a vital reason to understand what behaviors fall into what disorder categories: to understand the treatments that might work. But you also grapple with the line between pathological and non-pathological behaviors. It seems to me that you come to the understanding that we all have compulsions of one kind or another. It’s a gradient, and if it’s not really destructive to your life, they serve a therapeutic purpose in helping to relieve anxiety. Is that right?

Yes. I’ve been a science writer for a very long time and I’ve written about, among other things, neuroscience and psychology. Psychology and psychiatry have, over the years, tended to medicalize a lot of behaviors—to say that something is a mental disorder. The most infamous example was that psychiatry, until the ’70s, decided that homosexuality was a mental illness. Even before there was much of an organized psychiatric field of psychiatry, psychiatrists in the 1800s decided that slaves who ran away from their masters in the South must have a mental disorder, because no slave in his right mind would do that. So psychiatry has a very, very problematic history of slapping this label, mental illness, on behaviors that the powers that be just don’t like.

That was in the back of my mind as I started to explore these issues. And as I talked to people who were receiving treatment, but also people who just had mild compulsions, I absolutely came away with the conclusion that compulsions exist along a spectrum. Definitely, at one extreme of the spectrum, it is a mental illness. It is devastating to people, they deserve help and treatment and it is not to be minimized. But there are gradations. There is no way that everybody in the newsroom who’s constantly checking her iPhone to see if a source has gotten back to her is mentally ill. You cannot say that a huge fraction of the population is mentally ill. That doesn’t work.

I have a chapter on OCPD, Obsessive Compulsive Personality Disorder, for which I talked to a lot of people who in no way have a disorder but are a little bit compulsive. One reason this interested me was because even their slight compulsivity arose from the same source as extreme compulsivity: anxiety. One woman, who I think is in her sixties now, came to this country from Switzerland. She’s a piano tuner and mostly a homemaker. And she is compulsive about having everything in her house in exactly the right place. I mean, every bottle of spices in her kitchen, every mug, the stuff in the medicine cabinet in the bathroom, the way the towels are draped—everything has to be just so.

I asked her about how she grew up and her childhood. She told me her mother was very unpredictable emotionally. Some days she was warm and caring, other days she was cold and distant, and so this little girl never knew what kind of mother she was going to have. One day, the family is going to a summer cottage, and they get there and things are a mess and the mother is tearing at her hair, “Oh, we can’t fix it up quickly enough for the children to go to sleep, what are we going to do?” So the little girl says, “Even if we can’t get the whole house cleaned and perfect and the beds made, let’s just take this little place on the grass and brush away the sticks and put out some chairs and have a little picnic.” She told me that from that moment on, she began to think that even though many, many, many things in her life were unpredictable, there were a few things that she could control. And knowing that there were a few such things made her feel less on edge, less anxious. As an adult, she still feels the world is a crazy uncontrollable, unpredictable place, but by God, her mugs are going to be in the right place. That’s one little thing that she can control, and it makes her feel better. No one would call her mentally ill. She’s perfectly functional, she has great self-insight, but this is why she does what she does.

I think there are a lot of us who feel the same way. We can’t control what’s going to happen to the economy, we can’t control what’s going to happen in politics, but there is this one little area of our lives that we can carve out and we can control, and we do so compulsively. And thank goodness there are compulsive people in the world, people who just can’t sit still when something is bothering them, and they get up and they go out into the world and they do something.

There’s also this idea that disordered behaviors not only emerged from a place of trying to adapt to childhood circumstances, but also that they can be marshaled as strengths, which I really like. But to play devil’s advocate for a second: I recognize that compulsively maintaining order over your small corner of the world, like the woman you described, is not a sign of severe mental illness. She’s functional and it’s not hugely detrimental to her life, but at the same time, this behavior is symptomatic of a response to this unstable feeling she had throughout her childhood. So what do you think of the benefits of therapy for someone like that?

The simplest answer is that people can benefit from therapy even if they don’t have a mental illness. So I’m using mental illness in the very strict terms of the American Psychiatric Association. All the diagnoses in the DSM meet two crucial criteria: whatever the feelings or behaviors are, they have to cause distress and impairment. If they don’t, then the conversation is over, this person is not mentally ill. That actually came out of psychiatry’s unfortunate history with homosexuality.

Bianca, the woman we’re talking about, clearly is not mentally ill. She doesn’t feel like keeping her house in this state of extreme order is taking time away from things that she would be better off doing. Would she perhaps be more content with her life and have even more self-insight if she talked to a professional? Very likely. So again, I would just go back to saying, you can benefit from therapy even if you don’t have a mental illness. And many of the people I described don’t have mental illnesses, but they do have issues. So, you know, it’s up to them whether they want to get help for them.

Does anyone not have compulsions? Is that possible?

[Laughter] I think if you scratch the surface even a little bit, almost everyone will turn out to have at least a little something. I have no empirical basis for saying that, but once I started this research, I started seeing compulsions everywhere. And I, of course, have some of my own. So I think it would be hard to find someone who does not have at least mild compulsiveness, but again, that’s just a guess.

Can you talk about some of your own compulsions?

Yeah. I would describe myself as a non-hoarder, as in I really like to get rid of stuff in my house. I never really thought about it in psychological terms before: I just wanted to declutter. But once I started the book, it started to seem to me that when I have less stuff, I feel less tied down. The more stuff I have, I look around and think, “God, I will never be able to move,” or “I’ll never be able to make a change in my life.” So one of my mild compulsions is to get rid of things, and through the book and talking to people, both experts and civilians, I got that little teeny piece of insight into why I have that feeling.

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